Report Highlights Variations in Health Care for Children

Some Kids Likely Receiving Too Little or Too Much Health Care

January 08, 2014 04:10 pm Jonna Lorenz

The health care children receive varies greatly depending on where they live, according to the recent Dartmouth Atlas of Children's Health Care in Northern New England Report(www.dartmouthatlas.org) which raises questions about whether some patients may be missing out on recommended care while others may be receiving unnecessary treatments.

"I would love to see all doctors talking about variation in care, and how much variation is warranted and how to reduce care that's not warranted," said Nancy Morden, M.D., associate professor of community and family medicine at The Dartmouth Institute for Health Policy and Clinical Practice and co-author of the report.

The Dartmouth Atlas Project, which is funded principally by the Robert Wood Johnson Foundation, has studied variation in health care for more than 20 years. This is the project's first report on pediatric health care and is based on data from all-payer claims databases in Maine, New Hampshire and Vermont from 2007-2010. Those states are among the few that require routine reporting of medical claims from commercial insurance plans.

Story highlights
  • A new study on the health care children receive in northern New England demonstrates some large variations in care.
  • Such variations suggest that some children may be not receiving recommended care and other are receiving unnecessary care.
  • Family physicians in the area note that getting away from a strictly fee-for-service payment system and ensuring children have a primary care physician could alleviate these variations.

The Dartmouth Atlas Project, which is funded principally by the Robert Wood Johnson Foundation, has studied variation in health care for more than 20 years. This is the project's first report on pediatric health care and is based on data from all-payer claims databases in Maine, New Hampshire and Vermont from 2007-2010. Those states are among the few that require routine reporting of medical claims from commercial insurance plans.

The study divided the region into 69 hospital service areas and examined health care in three categories: health care proven to be effective; preference-sensitive care, for which benefits and risks are less clear; and supply-sensitive care, which often is tied to availability of services.

According to findings from the report,

  • office visits varied more than threefold, from 1.2 visits per child in Houlton, Maine, to 3.6 visits per child in St. Albans and Bennington, Vt.;
  • the rate of children who had at least one annual primary care visit from 2007-2010 ranged from 68 percent in Rumford, Maine, to 93 percent in Berlin, N.H.;
  • the rate of children who received appropriate testing for pharyngitis ranged from 41 percent in Calais, Maine, to 92 percent in Exeter, N.H.;
  • the rate of lead screening among children insured by Medicaid varied more than tenfold, from 8 percent in Dover-Foxcroft, Maine, to 86 percent in Berlin, N.H.;
  • the rate of children prescribed medication for attention-deficit/hyperactivity disorder who had a follow-up visit within 30 days of prescription varied from 17 percent in Pittsfield, Maine, to 70 percent in Newport, Vt.;
  • the overall rate of prescription drug use varied from three prescription drug fills per child in Townshend, Vt., to six fills per child in Caribou, Maine;
  • although antibiotic use varied only modestly, the use of antipsychotics varied more than fourfold, from 7.1 fills per 100 children in Newport, Vt., to more than 28 fills per 100 in Ellsworth and Bangor, Maine, and Franklin, N.H.;
  • the rate of tympanostomy tube insertion procedures per 1,000 children annually varied from 3.4 in Bangor, Maine, to 15.2 in Middlebury, Vt.;
  • the rate of tonsillectomies performed annually per 1,000 children varied fourfold, from 2.7 in Bangor, Maine, to 10.9 in Littleton, N.H; and
  • the rate of chest or abdominal CT scans per 1,000 children varied more than threefold, from 4.0 in Machias, Maine, to 15.4 in Bennington, Vt.

"We don't always know what the right amount of care is," Morden said. "The one thing that we can say with some confidence is (that spanning) both ends of the spectrum cannot represent quality care."

She said the report should be of interest to family physicians because it relates to the care they provide and to the referrals they make. "One of the most important things for family physicians is that our job is to understand evidence-based care, quality care and to advocate for our patients at all times."

More study and discussion is needed to determine appropriate levels of service and establish benchmarks, said Douglas Dreffer, M.D., vice president of the New Hampshire AFP and a family physician in Hillsborough, N.H.

"Most people agree that there's good evidence for about 30 percent of what we do," he said.

The report highlighted successes in those areas, pointing out that the rates of effective care are relatively high in northern New England based on National Committee for Quality Assurance measures. For example,

  • 90 percent of children throughout the region received appropriate treatment for simple upper respiratory infections, meaning they did not receive unnecessary antibiotics, and
  • 93 percent of children with asthma received appropriate medications annually.

Many factors can contribute to variations in care, including patient preferences, cultural beliefs, social and economic circumstances, costs, insurance, access to care, health system performance, and practice style.

The fee-for-service model is one factor Dreffer, Morden and other family physicians would like to see change.

"People get paid for the work they do in quantity, not quality. Until that changes, we're going to do more stuff," Dreffer said.

Improving access to primary care in rural areas also could improve consistency in care, said Judith Chamberlain, M.D., a family physician in Bruswick, Maine, and a former AAFP Board of Directors member.

According to the report, the ER is the only source of care after business hours in many rural communities. Additionally, children had more office visits and fewer ER visits in areas with more physicians.

"The rest of the story is helping people to understand that having a family physician as their primary source of care would be a way to lower their risk of getting unnecessary treatment and unnecessary medications," Chamberlain said. "But to do that, we need more family doctors and we need more of us in underserved areas."

In 2009, the supply of family physicians varied among hospital service areas in northern New England from a rate of 95.6 family physicians per 100,000 children in Laconia, N.H., to 427.1 per 100,000 children in Augusta, Maine, according to the report.

One objective in Vermont is identifying patients in need of primary care and bringing them in to a medical home, said Allyson Bolduc, M.D., president of the Vermont AFP and a family physician in Burlington, Vt.

"We can't take care of them unless we identify them," Bolduc said. "That's kind of the bottom line."

She said the report provides a basis for discussions about future statewide initiatives to improve children's health care. The Vermont AFP partners with the Vermont Department of Health, the Vermont chapter of the American Academy of Pediatrics and others on a variety of on topics, including asthma, obesity, prenatal care and depression.

"It's certainly very interesting," Bolduc said. "It's going to give us a lot to think about. I was really heartened to see that Vermont does pretty well overall in the analysis."

The Dartmouth Institute for Health Policy and Clinical Practice is working to get the information in the report out to physicians, including via publication in peer-reviewed journals.

"I would love for family doctors to go find their region and understand where they are on the spectrum," Morden said. "You don't know if what's going on in your community is kind of out there unless you know what's going on in the next community."


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